Provider Demographics
NPI:1447415104
Name:SOUTHERN CARDIOVASCULAR PLLC
Entity Type:Organization
Organization Name:SOUTHERN CARDIOVASCULAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:ELLICHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-259-2718
Mailing Address - Street 1:PO BOX 1135
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38027-1135
Mailing Address - Country:US
Mailing Address - Phone:901-259-2718
Mailing Address - Fax:901-259-1123
Practice Address - Street 1:6401 POPLAR AVE STE 410
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-259-2718
Practice Address - Fax:901-259-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526038Medicaid
TN1526038Medicaid